Technology appraisal guidance Published: 25 November 2015 nice.org.uk/guidance/ta367

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1 Vortioxetine for treating major depressive e episodes Technology appraisal guidance Published: 25 November 2015 nice.org.uk/guidance/ta367 NICE All rights reserved.

2 Contents 1 Guidance The technology The company's submission... 5 Clinical effectiveness... 5 Cost effectiveness ERG's critique of clinical effectiveness ERG's critique of cost effectiveness Company's additional evidence ERG's critique of the company's additional evidence Consideration of the evidence Clinical effectiveness Cost effectiveness Summary of Appraisal Committee's key conclusions Implementation Review of guidance Appraisal Committee members, guideline representatives and NICE project team Appraisal Committee members NICE project team Sources of evidence considered by the Committee About this guidance NICE All rights reserved. Page 2 of 63

3 1 Guidance 1.1 Vortioxetine is recommended as an option for treating major depressive episodes in adults whose condition has responded inadequately to 2 antidepressants within the current episode. 1.2 People whose treatment with vortioxetine is not recommended in this NICE guidance, but was started within the NHS before this guidance was published, should be able to continue treatment until they and their NHS clinician consider it appropriate to stop. NICE All rights reserved. Page 3 of 63

4 2 The technology 2.1 Vortioxetine (Brintellix, Lundbeck) is an antidepressant that is thought to exhibit its clinical effect through direct modulation of receptor activity and inhibition of the serotonin transporter. Vortioxetine has a marketing authorisation in the UK 'for the treatment of major depressive episodes in adults'. 2.2 The summary of product characteristics lists the following 'common' and 'very common' adverse reactions for vortioxetine: abnormal dreams, constipation, diarrhoea, dizziness, itching, nausea and vomiting. For full details of adverse reactions and contraindications, see the summary of product characteristics. 2.3 Vortioxetine is administered orally. The recommended starting dosage is 10 mg once daily in adults younger than 65 years, and 5 mg once daily in adults 65 years and older. Depending on how the symptoms respond, the dose may be increased to a maximum of 20 mg once daily or decreased to a minimum of 5 mg once daily. Treatment for at least 6 months is recommended after the symptoms resolve. The price of a pack (28 tablets) of 5 mg, 10 mg or 20 mg tablets is (excluding VAT; company's submission). Costs may vary in different settings because of negotiated procurement discounts. NICE All rights reserved. Page 4 of 63

5 3 The company's submission The Appraisal Committee (section 7) considered evidence submitted by Lundbeck and a review of this submission by the Evidence Review Group (ERG; section 8). Clinical effectiveness 3.1 The company conducted a systematic review of the literature to identify studies evaluating the clinical effectiveness and safety of vortioxetine for treating adults having a moderate-to-severe major depressive episode. These adults included those who had not tolerated initial antidepressant treatment or whose condition had responded inadequately to it, and who needed further antidepressant therapy (hereafter referred to as the 'second-line population'). Therefore, in its original submission, the company did not include in its analyses all adults with major depressive disorder, as specified in NICE's final scope and vortioxetine's marketing authorisation. In its original submission, it identified 2 phase III randomised controlled trials, REVIVE and TAK REVIVE was an international (14 European countries including the UK), double-blind, randomised, active-control trial. It included 501 adults with a single episode of moderate-to-severe major depressive disorder or recurrent major depressive disorder whose condition had inadequately responded to monotherapy with a selective serotonin reuptake inhibitor (SSRI) or a serotonin norepinephrine reuptake inhibitor (SNRI). Patients were randomised 1:1 to flexible doses of vortioxetine (10 20 mg daily; starting dose 10 mg daily), or agomelatine (25 50 mg daily; starting dose 25 mg daily). Patients were assessed weekly during the first 4 weeks of treatment and then every 4 weeks until the end of the 12-week treatment period. A further safety assessment was scheduled 4 weeks after completing or withdrawing from the study. Most patients enrolled into REVIVE were women (74.7%), most were white (99.8%), the mean age was 46.3 years and they had a mean of 2.5 previous major depressive episodes. The company stated that both groups had comparable baseline Montgomery Åsberg Depression Rating Scale (MADRS) scores and previous antidepressant use. Most patients received the maximum dosage of vortioxetine (20 mg, 64.7%) and agomelatine (50 mg, 71.7%) from weeks 4 to 12. NICE All rights reserved. Page 5 of 63

6 3.3 The primary outcome measure in REVIVE was change in MADRS score from baseline to week 8 (MADRS is a rating scale consisting of 10 items, each rated 0 [no symptom] to 6 [severe symptom], contributing to a total score from 0 to 60; the higher the score, the more severe the condition). A 'full analysis set' population (that is, people who were randomised into the study and had a baseline assessment and at least 1 further assessment) was used to analyse the efficacy outcomes. The company tested a primary hypothesis of non-inferiority. Non-inferiority was considered established if the upper bound of the two-sided 95% confidence interval of the difference between treatment groups in MADRS total score at week 8 did not exceed +2 MADRS units compared with agomelatine. The mean change from baseline in MADRS total scores at week 8 were 16.5 and 14.4 points in the vortioxetine group and the agomelatine group respectively. This resulted in a mean difference of 2.16 points in favour of vortioxetine (95% confidence interval [CI] 3.51 to 0.81; see table 1). 3.4 Pre-specified subgroup analyses of the primary outcome were carried out by the company for sex, age, baseline severity, baseline anxiety and class of prior antidepressant. The company stated that these analyses suggested that vortioxetine improved the MADRS score compared with agomelatine across all pre-specified subgroups. 3.5 The company stated that vortioxetine statistically significantly improved outcomes compared with agomelatine across the analyses of outcomes reflecting response and remission measured by MADRS score (see table 2). Response is defined as a 50% or more decrease from baseline in the MADRS. Remission is defined as a MADRS total score of 10 or less. Table 1 Company's analysis of primary outcome in REVIVE Outcome Vortioxetine: difference compared with agomelatine Week 8 MMRM Week 12 LOCF,, ANCOVA MMRM LOCF,, ANCOVA Δ MADRS total score 2.16* 1 3.1** 2.03* 3.5** ( 3.51 to 0.81) ( 3.45 to 0.60) NICE All rights reserved. Page 6 of 63

7 Δ=mean change from baseline. 1 Primary efficacy analysis. *p<0.01; **p<0.001 compared with agomelatine. Vortioxetine: baseline n=252, week 8 n=220, week 12 n=200. Agomelatine: baseline n=241, week 8 n=190, week 12 n=178. Abbreviations: ANCOVA, analysis of covariance; LOCF, last observation carried forward; MADRS, Montgomery Åsberg Depression Rating Scale; MMRM, mixed model for repeated measures; n, number. Table 2 Response and remission in REVIVE Response (MADRS) Remission (MADRS) Week 8 Vortioxetine 62%** 41%** Agomelatine 47% 30% Adjusted odds ratio (95% CI) 1.81 (1.26 to 2.60) 1.72 (1.17 to 2.52) Week 12 Vortioxetine 70%** 55%*** Agomelatine 56% 39% Adjusted odds ratio (95% CI) 1.83 (1.26 to 2.65) 2.01 (1.39 to 2.90) *p <0.05; **p <0.01; ***p <0.001 compared with agomelatine. Abbreviations: CI, confidence interval; MADRS, Montgomery Åsberg Depression Rating Scale. 3.6 Health-related quality of life was measured at baseline and at weeks 4, 8 and 12 in the REVIVE trial using the EuroQol-5 dimensions survey (EQ-5D, see table 3). Table 3 EQ-5D summary scores and changes in EQ-5D score from baseline Assessment Vortioxetine Agomelatine p value n Mean Change from n Mean Change from (SD) baseline 1 (SD) baseline 1 NICE All rights reserved. Page 7 of 63

8 Baseline (0.28) Week (0.22) Week (0.19) Week (0.21) (0.27) (0.27) (0.23) (0.22) 0.08 < Based on a mixed model for repeated measures analysis. Abbreviations: n, number; SD, standard deviation. 3.7 TAK318 was a multicentre (62 centres in USA and Canada), double-blind, randomised, active-control trial including 447 adults with stable major depressive disorder experiencing treatment-emergent sexual dysfunction. Patients were randomised 1:1 to flexible doses of vortioxetine (10 20 mg daily; starting dose 10 mg daily), or escitalopram (10 20 mg daily; starting dose 10 mg daily). Patients were assessed at the end of the 8-week treatment period and had an additional safety assessment 3 weeks after study completion. 3.8 The primary outcome measure in TAK318 was change from baseline in the Changes in Sexual Functioning Questionnaire Short-Form 14 (CSFQ-14) total score after 8 weeks of treatment (total score ranges from 14 to 70; higher scores reflect higher sexual functioning). A 'full analysis set' population was used to analyse the efficacy outcomes. Sexual functioning improved in both the vortioxetine and escitalopram groups, with a mean difference of 2.2 points in favour of vortioxetine compared with escitalopram (p=0.013). 3.9 The company conducted both a Bayesian indirect treatment comparison and a frequentist indirect treatment comparison using the Bucher method for 2 outcomes: probability of remission, and the proportion of people who stop treatment because of adverse events. The company systematically searched the literature and identified the REVIVE trial plus 3 additional multicentre, blinded, randomised, controlled trials comparing: agomelatine with sertraline (Kasper et al. 2010); venlafaxine with citalopram (Lenox-Smith et al. 2008); and bupropion with sertraline or venlafaxine (STAR*D). The company excluded: NICE All rights reserved. Page 8 of 63

9 Rosso et al. (2012), which compared bupropion with duloxetine, because it considered the method of randomisation (by day of the week) and blinding (single-blind) inadequate 2 placebo-controlled trials because the company's clinical advisers suggested that people who enrol in placebo-controlled trials may be different from those in active-controlled studies, but the company included these trials in a sensitivity analysis. The company stated that its searches did not identify any evidence to include on 2 other relevant comparators (fluoxetine or mirtazapine) in the indirect treatment comparison Kasper et al. (2013) was a post-hoc analysis of the 'pre-treated' population from 2 trials of agomelatine in people with major depressive disorder. The number of patients enrolled in each of the 4 trials ranged from fewer than 100 (Kasper) to 789 (STAR*D). The mean age of patients was reported for 3 of the 4 trials and ranged from 41.8 years (STAR*D) to 46.3 years (REVIVE). Baseline severity measured by Hamilton Depression Rating Scale (HAM-D) was between 18.9 (STAR*D) and more than 31.0 (Lenox-Smith et al. 2008), but the company considered that the differences between the trials would not have had an impact on the treatment effect. In general, STAR*D enrolled a higher proportion of men who were younger and whose depression was less severe than the populations in the other trials. Outcomes were assessed at different time-points in the trials, from 6 weeks (Kasper) to 14 weeks (STAR*D). Each study measured depressive symptoms (and hence remission) using different scales: MADRS (REVIVE), HAM-D 17 (Kasper, STAR*D) and HAM-D 21 (Lenox-Smith). However, the company stated that each trial used clinically accepted cut-off rates for remission, which are generalisable regardless of the scale used The company stated that the results of its indirect treatment comparison suggested that vortioxetine works better and is better tolerated than the comparators. The results of the company's indirect treatment comparison are presented in tables 4 and 5. The company stated that it did not assess heterogeneity because of the small number of studies included in the network. NICE All rights reserved. Page 9 of 63

10 Table 4 Summary of results of company's frequentist indirect treatment comparison Treatment Remission rate People stopping treatment because of adverse events ents (withdrawal) wal) Rate Risk difference versus 95% CI Rate Risk difference versus 95% CI (%) vortioxetine (%) (%) vortioxetine (%) Vortioxetine 40.5 n/a n/a 5.9 n/a n/a Agomelatine to 2.6 Sertraline to 1.1 Venlafaxine to 9.9 Bupropion to 6.4 Citalopram to to to to to to 24.5 Abbreviation: CI, confidence interval; n/a, not applicable. Table 5 Summary of results of company's Bayesian indirect treatment comparison Treatment Remission rate People stopping treatment because of adverse events ents (withdrawal) wal) Rate Odds ratio vortioxetine 95% Rate Odds ratio vortioxetine 95% (%) versus comparator ator (%) CrI (%) versus comparator ator (%) CrI Vortioxetine 40.5 n/a n/a 5.9 n/a n/a Agomelatine to 2.37 Sertraline to to to 0.62 NICE All rights reserved. Page 10 of 63

11 Venlafaxine to 3.07 Bupropion to 3.77 Citalopram to to to to 0.86 Abbreviation: CrI, credible interval; n/a, not applicable The company presented short-term safety data from REVIVE. About half of patients in each treatment group had 1 or more adverse reaction over the 12-week treatment period. Adverse reactions with an incidence of 5% or more for vortioxetine or agomelatine respectively were: nausea (16.2% and 9.1%), headache (10.3% and 13.2%), dizziness (7.1% and 11.6%) and somnolence (4.0% and 7.9%). Fewer patients in the vortioxetine group (1.2%) compared with the agomelatine group (1.7%) experienced serious adverse events. Fewer patients stopped treatment because of adverse events in the vortioxetine group (5.9%) than in the agomelatine group (9.5%) The company also presented safety data from 5 open-label long-term extension studies including a total of 2587 patients, of which 54% received vortioxetine for 52 weeks or more. The overall incidence of adverse reactions was 74.6%, and was higher in the mg dose group (78.9%) than in the mg group (71.2%). Cost effectiveness 3.14 The company did not identify any published studies of the cost effectiveness of vortioxetine for treating the second-line population. It submitted a decision tree model with a Markov component to include subsequent treatment switches to third and later lines. It assumed that a patient can be offered 1 of 5 treatments: vortioxetine, agomelatine, citalopram, sertraline and venlafaxine. The company conducted the economic analysis from an NHS and personal social services perspective and chose a time horizon of 12 months so did not discount costs and NICE All rights reserved. Page 11 of 63

12 health effects. A half-cycle correction was applied to the health effects but not the costs in the Markov part of the model (cycle length 2 months) The company stated its economic model represented a single major depressive episode. Hypothetical patients entered the model with major depressive disorder that had not responded to initial therapy. The decision tree included: an acute phase of treatment of 8 weeks (months 0 2) a maintenance phase of 6 months (months 2 8) and a recovery phase of 4 months' duration (months 8 12). The time that patients spent in the decision tree varied and depended on whether treatment was successful in each phase. If treatment succeeded in all 3 phases, with remission achieved and sustained to recovery, a hypothetical patient spent the entire 12 months in the decision tree model. The company's economic model also included events in which treatment was not successful (lack of remission or adverse events). These events led to a further treatment, that is, to third and subsequent lines of treatment. Patients who did not complete the acute or maintenance phase left the decision tree model and entered the Markov component. In a given cycle of the Markov component, a patient's condition could either remit or not. In its original economic model, the company assumed that patients remained on treatment for 6 months after their condition had remitted in the acute phase unless they experienced a long-term adverse reaction (insomnia, sexual dysfunction or weight gain) The company took data on the probability of remission after 8 weeks of treatment (acute phase) from its indirect treatment comparison (see table 4). The company assumed that a person's probability of relapse depended on the line of treatment rather than a specific drug: initial second-line treatment (14.2%, from Limosin et al. 2004), third-line treatment (25.0%, from STAR*D), and fourth- plus fifth-line treatment (42.6%, from STAR*D). STAR*D was a prospective, sequentially randomised controlled trial of outpatients with nonpsychotic major depressive disorder who received 1 (n=3671) to 4 (n=123) successive acute treatment steps, including treatment combinations and augmented therapies. Patients who relapsed during the maintenance phase (which the company assumed occurred halfway through this phase) could switch to third and subsequent lines of treatment. The company assumed that NICE All rights reserved. Page 12 of 63

13 clinicians then assessed these patients for remission 2 months after starting third-line treatment. It took the data reflecting the proportion of patients whose condition was in remission after each line of treatment from STAR*D: third- (13.7%), fourth- (13.0%) and fifth-line treatment (13.0%). The company considered that patients who had not relapsed after 6 months of maintenance treatment had recovered. These patients stopped treatment and the company assumed that they could not experience recurrent depression Resource use and costs in the company's economic model included those for treatment (drug), adverse events and each health state (that is, monitoring, inpatient and outpatient admissions). The company based drug costs on the list prices from the 'Monthly Index of Medical Specialities'. Dosages in the acute phases were based on the World Health Organization Defined Daily Dose (for example, 10 mg daily for vortioxetine), and dosages in the maintenance phase were based on the mean dose reported at the end of trials included in the company's indirect treatment comparison. The company took data for health state resource use for the acute phases from an unpublished interim analysis of the PERFORM study (n=226, which included people previously untreated) and, for the maintenance phase, from Byford et al. (2011; the General Practice Research Database 2001/06 88,935 people with depression and at least 2 antidepressant prescriptions). The company took data for the health state costs from Unit Costs of Health and Social Care (2013) and NHS Reference Costs. The company assumed that no treatments were prescribed to manage adverse events, but that around one-third of people would incur an additional GP visit. Therefore, the company costed all adverse events based on an assumed 0.3 GP visits per patient per adverse event ( 13.50) To estimate health-related quality of life in the acute phase, the company used EQ-5D data from REVIVE (see table 6). However, in its original economic model for the maintenance phase, the company used EQ-5D data from Sapin et al. (2004). Sapin was a French study that included 250 people with major depressive disorder in primary care, and assessed health-related quality of life at baseline and after 8 weeks of treatment. The company noted that the mean MADRS score at baseline was 32.7 in Sapin compared with 29.1 in REVIVE, which may explain why the baseline EQ-5D score from Sapin was lower than that in REVIVE. The company included disutility values associated with adverse events from Sullivan et al. (2004), and applied them for 3 weeks in the company's base case analysis. NICE All rights reserved. Page 13 of 63

14 Table 6 Summary of utility values used in company's economic model Event Utility value Comment Source Acute phase (0 8 weeks) Depression (baseline) 0.54 None Remission 0.85 No remission 0.62 Weighted average of people whose depression had not responded to treatment and people whose depression had responded but not remitted at 8 weeks REVIVE Maintenance phase (after 8 weeks) Remission 0.85 Relapse/no remission 0.58 EQ-5D score for people whose depression had remitted or responded to treatment EQ-5D score for people whose depression had not responded to treatment Sapin et al Recovery 0.85 Assumed equal to remission Disutility values (decrements) of adverse eventsents Sexual dysfunction Headache Diarrhoea Somnolence None Assumed equal to drowsiness Sullivan et al Nausea Assumed average of gastrointestinal adverse events Insomnia Assumed equal to anxiety Dry mouth Dizziness Sweating No data available, so company assumed no decrement Not applicable NICE All rights reserved. Page 14 of 63

15 Weight gain Company calculation Dixon et al and REVIVE 3.19 The company's deterministic cost-effectiveness results for vortioxetine compared with the comparators in the second-line population are presented in table 7. Table 7 Company's base-case cost-effectiveness eness results for vortioxetine in people having second-line treatment Technology Total costs ( ) Total QALYs Incremental costs ( ) Incremental QALYs ICER ( /QALY) Venlafaxine n/a n/a n/a Vortioxetine Citalopram Dominated Sertraline Dominated Agomelatine Dominated Dominated: fewer QALYs at greater cost than comparator. Abbreviations: ICER, incremental cost-effectiveness ratio; n/a, not applicable; QALY, quality-adjusted life year The company explored parameter and structural uncertainty in its economic model by presenting the results of 1-way sensitivity analyses, scenario analyses and a threshold analysis. The 1-way sensitivity analyses suggested the company's cost-effectiveness results were most sensitive to: the difference in remission rates at 8 weeks (acute phase) between vortioxetine and each comparator GP consultation costs the utility value for remission at 8 weeks NICE All rights reserved. Page 15 of 63

16 the utility value for relapse after 8 weeks. However, in all but 2 of the company's 1-way sensitivity analyses, vortioxetine dominated other treatments (was more effective and cost less) or had an incremental cost-effectiveness ratio (ICER) below 15,670 per quality-adjusted life year (QALY) gained. Vortioxetine was dominated by venlafaxine and by citalopram when the lower bound of the 95% confidence interval was included for the differences in remission rates at 8 weeks. The company commented that its scenario analyses showed that its economic model was robust to all of the structural assumptions and remained the most cost-effective treatment. Because the remission rate at 8 weeks was the most influential driver of the company's cost-effectiveness results, it explored a threshold analysis around this parameter for vortioxetine, see table 8. Table 8 Company's threshold analysis of remission rate for vortioxetine Treatment Remission rate at 8 weeks 20,000 per QALY gained threshold Remission rate at 8 weeks 30,000 per QALY gained threshold Vortioxetine (base case) 40.50% n/a 40.50% n/a Vortioxetine 30.53% n/a 30.10% n/a Venlafaxine 33.30% 20, % 29,898 Vortioxetine 27.97% n/a 28.54% n/a Agomelatine 29.50% 20, % 29,973 1 Vortioxetine 24.53% n/a 24.00% n/a Sertraline 26.10% 20, % 30,062 Vortioxetine 24.10% n/a 23.55% n/a Citalopram 23.70% 20, % 29,975 Figures in bold are base case remission rates. 1 Threshold ICERs between vortioxetine and agomelatine are based on lower cost and fewer QALYs for vortioxetine, so the ICERs should be interpreted as willingness to accept QALYs lost, not willingness to pay for QALYs gained. Abbreviations: ICER, incremental cost-effectiveness ratio; n/a, not applicable; QALY, quality-adjusted life year. NICE All rights reserved. Page 16 of 63

17 ERG's critique of clinical effectiveness 3.21 The ERG stated that the reporting of the company's searches were clear and appropriate. The ERG noted that the company presented no evidence to suggest that the relative efficacy between non-ssris may vary between first- and second-line use (and beyond). It stated that it would be more appropriate to include the full evidence base for vortioxetine and its comparators, rather than restricting the evidence base from the outset to the second-line population, so excluding 22 of the 24 completed studies of vortioxetine The ERG commented that REVIVE and TAK318 appeared well conducted but raised the following concerns: Both trials included comparators of limited relevance to clinical practice in England (NICE has not issued any guidance for agomelatine). Both trials were short considering the duration of treatment recommended by NICE to achieve and consolidate remission, so evidence of long-term efficacy was uncertain. Both trials evaluated the efficacy of vortioxetine mg daily, so the efficacy of the licensed 5 mg daily regimen was uncertain The ERG commented that the population enrolled into REVIVE was broadly representative of the second-line population in England. For example, baseline MADRS scores ranged from points, which is consistent with people with moderate-to-severe major depressive disorder. However, the ERG noted that: most patients were white (99.8%), which is unlikely to be reflective of the second-line population in England 23% of patients had received an SNRI as initial treatment, which is not reflective of clinical practice in England, where first-line SNRI use is negligible most patients were recruited from an outpatient psychiatric setting (97.2%) the proportion of patients from the UK was small (about 7%) The ERG noted that, although the efficacy analyses in REVIVE and TAK318 used a modified intention-to-treat analysis (that is, full analysis set rather than including all randomised patients), the risk of bias was likely to be low because relatively few patients randomised were excluded. NICE All rights reserved. Page 17 of 63

18 3.25 The ERG commented that the results from the company's analysis of the primary and secondary outcomes from REVIVE had relatively wide confidence intervals, so the size of the difference in efficacy between vortioxetine and agomelatine was uncertain (see tables 1 and 2) The ERG agreed with the company's assessment of bias for Rosso et al. (2012), so considered it was reasonable to exclude it, but noted it was the only trial that indirectly compared vortioxetine with duloxetine. The ERG stated that it was questionable whether Kasper et al. (2013) was suitable for inclusion in the indirect treatment comparison. It stated that it was unclear whether the population consisted entirely of patients receiving second-line treatment, or whether it also included those who had been treated for a previous depressive episode in the last 12 months but were starting first-line treatment for a current major depressive episode The ERG stated that it had significant concerns over the validity of the company's indirect treatment comparison because of the differences in the baseline patient characteristics and severity of depression of the populations across the 4 trials. It also stated that time of outcome assessment between trials (varying from 6 14 weeks) may also affect the results because rates of remission and withdrawal are likely to be time-dependent. The ERG concluded that the heterogeneous nature of data included in the network meant that the results may not be reliable The ERG highlighted that there was little evidence of a statistically significant improvement in the efficacy for vortioxetine compared with the comparators, given that the results from the company's indirect treatment comparison had wide confidence intervals. It stated that the findings in each specific trial drove the results of the company's indirect treatment comparison because of the sparse evidence network (that is, each arm of the network was informed by 1 trial). The ERG noted that basing results on risk differences was potentially inappropriate because they may be sensitive to the heterogeneity across trials (see table 4). However, it acknowledged that the company's results based on odds ratios were largely consistent (see table 5). The ERG also commented that the results from the company's sensitivity analysis including the 2 placebo-controlled trials were broadly similar to those that excluded them. NICE All rights reserved. Page 18 of 63

19 3.29 The ERG stated that there was no evidence to suggest the relative efficacy between drugs that were not classified as SSRIs (for example, SNRIs) vary between first- and second-line treatment (and beyond) (see section 3.21). Therefore, it sought further evidence from the company on a first-line population during the clarification stage: The ERG re-analysed data from a published meta-analysis of placebo-controlled trials with active reference treatment arms (Pae et al. 2015). Pae compared vortioxetine with agomelatine (1 trial), duloxetine (5 trials) and venlafaxine (1 trial). The ERG noted that both the European Medicines Agency and the company have criticised the use of trials including active references because they are not true randomised comparisons, given that patients whose condition is known to be non-responsive to the reference treatment are excluded, possibly biasing results in favour of the active reference. The ERG accepted the potential for such bias, but did not consider it substantial enough to exclude these trials. The ERG stated that Pae found no evidence of any difference in efficacy between vortioxetine and venlafaxine, and that vortioxetine was less effective than duloxetine in reducing depression scores, or achieving response and remission. Llorca et al. (2014) published an indirect treatment comparison that included 57 placebo controlled trials of the following drugs: vortioxetine, agomelatine, desvenlafaxine, duloxetine, escitalopram, sertraline, venlafaxine, vilazodone. Llorca found no evidence of any difference in efficacy between vortioxetine and its comparators. The ERG commented that there was evidence to suggest fewer people stop vortioxetine because of adverse events than other treatments, including sertraline and venlafaxine. The ERG considered that Llorca may represent the most reliable evidence for comparing vortioxetine with other treatments The ERG concluded that, based on all the evidence, vortioxetine is likely to be similar in efficacy to other antidepressants, but may be superior to agomelatine and inferior to duloxetine The ERG agreed that vortioxetine appears generally safe and tolerable in people with major depressive disorder. The ERG stated that, although the incidence of adverse events was high in people taking vortioxetine, most were mild to moderate in nature, and there was no conclusive evidence that they were dose-dependent. NICE All rights reserved. Page 19 of 63

20 3.32 The ERG also concluded that vortioxetine may have a better overall safety profile than other antidepressants, but sparse comparative data for adverse events prevented the ERG making a firm conclusion. ERG's critique of cost effectiveness 3.33 The ERG stated that the company developed an unnecessarily complicated model structure, and that it was unclear why: The company used different modelling approaches in the maintenance and recovery periods, rather than an initial decision tree for the acute phase and then a separate Markov component for all people in the subsequent 10-month period. The company assumed different time-points for relapse (after 3 months) and stopping treatment in the maintenance phase because of adverse reactions (after 1 month), which favoured those treatments with higher acquisition costs. The ERG noted that this introduced inconsistency between the timing of relapse for people within the decision tree and Markov components The ERG commented that basing the decision to change treatments solely on remission data at 8 weeks was an important limitation of the company's original economic model. It stated that the company's model therefore excluded people whose condition responded to treatment partially but had not remitted and that, in clinical practice, clinicians use response in deciding whether to continue treatments. The ERG commented that the company also used the 8-week remission data in its original economic model to inform decisions to change treatment at 4 weeks in the model. The ERG explained that this ignored the costs of additional treatment for people whose disease responded but did not remit. It also explained that it may have overestimated health benefits for people whose disease remits because it assigned a utility value based on health improvements demonstrated over 8 weeks rather than 4 weeks. The ERG concluded that the company's base case may have underestimated vortioxetine's costs and overestimated vortioxetine's benefits The ERG noted that: Because the company had assumed that a person's depression was not at risk of recurrence in the recovery phase, it introduced a potential bias in favour of the most effective initial treatment. The ERG agreed that the risk of relapse (or recurrence) may NICE All rights reserved. Page 20 of 63

21 be different in later phases than in earlier phases of the condition, but that assuming no risk of recurrence seemed overly optimistic. The company had assumed that people remain on treatment for 6 months after remission in the maintenance phase. The ERG considered that this was reasonable and consistent with NICE's guideline on depression in adults, but was aware that NICE recommends 2 years of continued treatment in people considered to be at high risk of relapse. The ERG acknowledged that the company explored both of these assumptions in the response to clarification by varying the time-horizon of the model from 8 months (no recovery period) up to 2 years (treatment and monitoring costs continued in the recovery period). The ERG concluded that, although the company's base-case analysis was robust to these scenarios, the ICER for vortioxetine compared with the next most cost-effective treatment was higher than in the company's base-case analysis, suggesting that including the original assumptions had potentially favoured vortioxetine The ERG stated that a half-cycle correction for both costs and utility values would have been appropriate, rather than for utility values only, because different health states are associated with different costs for consultation or hospitalisation The ERG highlighted that using a 12-month time horizon was reasonable for the 'average' patient because an untreated major depressive episode is estimated to last 5 6 months (World Health Organization 2008). However, the ERG noted that some people may be treated for longer than 12 months and therefore 12 months may not have been sufficient to capture all of the relevant costs and benefits The ERG highlighted that there was uncertainty around whether STAR*D was an appropriate study to inform the prognosis of people with depression whose condition had not remitted after second-line treatment. The ERG considered that STAR*D included treatments that did not reflect the comparators in the model, and that the population of STAR*D was different from the population of REVIVE. It explained that using data from STAR*D for third- and later lines of treatment imposed a poorer prognosis (that is, lower remission rates and higher relapse rates) than expected for a population with the same characteristics as in REVIVE. The ERG stated that using STAR*D may have made the most effective NICE All rights reserved. Page 21 of 63

22 second-line treatment look even better (that is, vortioxetine in the company's base case analysis) The ERG disagreed with the company's decision to use the same utility value for relapse, and for people whose condition was not in remission after 3 or more treatments. This was because they are very different health states. It highlighted that the utility value from Sapin et al. (2004), used by the company for people whose condition had not remitted, was lower than the utility value reported for people whose condition had not remitted at week 8 in the REVIVE trial. The ERG considered that it was not necessary to use a different source for the utility values in the maintenance phase, and that using these 2 sources (REVIVE and Sapin et al. 2004) favoured vortioxetine in the company's base-case analysis. It also felt that the relapse health state should have reflected the recurrence of moderate-to-severe major depression and so the baseline level of utility (that is, 0.54). The ERG proposed alternative utility values for the company's model, see table 9. Table 9 ERG's preferred utility values Health state Company's utility Company's source ERG's utility ERG's source No remission (0 8 weeks) No remission (after 8 weeks) 0.62 REVIVE Sapin (2004) 0.67 REVIVE (FAS, MMRM) Relapse (after 8 weeks) 0.58 Sapin (2004) 0.54 REVIVE (baseline depression) Abbreviations: ERG, Evidence Review Group; FAS, full analysis set; MMRM, mixed model for repeated measures Given the issues highlighted by the ERG around the company's indirect treatment comparison (see sections 3.26 to 3.28), the ERG stated that there was considerable uncertainty associated with the ICERs. It concluded that the company's base-case analysis can only be reliably used for comparisons of vortioxetine with agomelatine. NICE All rights reserved. Page 22 of 63

23 3.41 The ERG was aware from the World Health Organization (2008) that an untreated major depressive episode lasts on average 5 6 months. The ERG calculated the average duration of a major depressive episode for each treatment included in the company's model based on approximating the mean number of months not spent in the remission and recovery health states. The ERG highlighted that the lowest estimated duration for a major depressive episode for any given treatment in the company's model was for vortioxetine (6.73 months; longer than the 5 6 months stated by the World Health Organization). The ERG explained that this assumed implicitly that people who change treatment have a poorer prognosis compared with the broader major depressive disorder population. This therefore highlighted that the sources used to inform the parameters for remission and relapse for third- and later lines of treatment in the company's model were crucially important (for example, STAR*D) The ERG presented deterministic ICERs for several exploratory analyses for second-line treatment using the company's original economic model. These exploratory analyses used alternative sources of evidence for the relative effectiveness of vortioxetine compared with its comparators (see section 3.29 and table 10) and used the ERG's preferred utility values (see table 9). Exploratory analysis 1 (see table 11): The dosage of treatment was up-titrated after 8 weeks (maintenance phase). STAR*D was used to inform remission and relapses rates for third- and later lines of treatment. Exploratory analysis 2 (see table 12): The same dosage of treatment was used for the acute and mainanteance phases rather than up-tritrated after 8 weeks. STAR*D was used to inform remission and relapses rates for third- and later lines of treatment. Exploratory analysis 3 (see table 13): The dosage of treatment was up-titrated after 8 weeks. NICE All rights reserved. Page 23 of 63

24 The remission rate for all treatments used third and subsequent lines of treatment was assumed to be equal to the average of the remission rates of the second-line comparators. Therefore, the ERG assumed that the absolute rate of remission did not change from third and subsequent lines of treatment. The same rate of relapse was applied for second and subsequent lines of treatment rather than based on the line of treatment (relapse rate taken from Limosin et al. 2004). Exploratory analysis 4 (see table 14): The dosage of treatment was up-titrated after 8 weeks For third and subsquent lines of treatment, all treatments had the same remission rates. However, the remission rates declined after each line of treatment. The ERG took the average of the remission rates of the second-line comparators and calculated the remission rates for third and subsequent lines of treatment by applying a proportionate reduction based on the STAR*D trial. The same rate of relapse was applied for second and subsequent lines of treatment rather than based on the line of treatment (relapse rate taken from Limosin et al. 2004). Table 10 ERG's alternative e scenarios for relative e effectiveness: eness: proportion of remitters at 8 weeks Probability of remission Treatment Company submission (from ITC) ERG scenario 1 (Llorca et al. 2014) ERG scenario 2 (Pae et al. 2015) ERG scenario 3 (equal effectiveness) eness) Vortioxetine 40.5% 40.5% 40.5% 40.5% Agomelatine 29.5% 35.8% 26.5% 40.5% Sertraline 26.1% n/a n/a n/a Venlafaxine (XR) 33.3% 49.7% 42.5% 40.5% Duloxetine n/a 43.2% 49.3% 40.5% Citalopram 23.7% n/a n/a n/a NICE All rights reserved. Page 24 of 63

25 Escitalopram n/a 40.7% n/a 40.5% Abbreviations: ERG, Evidence Review Group; ITC, indirect treatment comparison; n/a, not applicable; XR, extended release. Table 11 ERG exploratory analysis 1 using STAR*D data (with up-titration) Incremental ICER Costs QALYs Costs QALYs with SSRI without SSRI (incremental analyses, in relation to next best) ERG scenario 1: Llorca et al. (2014) Venlafaxine (XR) Ref Ref Ref Ref Escitalopram Dominated n/a Vortioxetine Dominated Dominated Duloxetine 1, Dominated Dominated Agomelatine 1, Dominated Dominated ERG scenario 2: Pae et al. (2015) Venlafaxine (XR) Ref Ref Ref Ref Vortioxetine ,191 9,191 Duloxetine 1, ,393 13,393 Agomelatine 1, Dominated Dominated ERG scenario 3: Equal effectivenesseness Escitalopram Ref Ref Ref n/a Venlafaxine (XR) Dominated Ref Vortioxetine ,188 5,318 Duloxetine 1, Dominated Dominated NICE All rights reserved. Page 25 of 63

26 Agomelatine 1, , ,927 Dominated fewer QALYs at greater cost than comparator. Abbreviations: ERG, Evidence Review Group; ICER, incremental cost-effectiveness ratio; n/a, not applicable; QALY, quality-adjusted life year; Ref, reference comparator; SSRI, selective serotonin re-uptake inhibitor; XR, extended release. Table 12 ERG exploratory analysis 2 using STAR*D data (without up-titration) Incremental ICER Costs QALYs Costs QALYs with SSRI without SSRI (incremental analyses, in relation to next best) ERG scenario 1: Llorca et al. (2014) Venlafaxine (XR) Ref Ref Ref Ref Escitalopram Dominated n/a Vortioxetine Dominated Dominated Duloxetine Dominated Dominated Agomelatine 1, Dominated Dominated ERG scenario 2: Pae et al. (2015) Venlafaxine (XR) Ref Ref Ref Ref Duloxetine ,676 4,676 Vortioxetine Dominated Dominated Agomelatine 1, Dominated Dominated ERG scenario 3: Equal effectivenesseness Escitalopram Ref Ref Ref n/a Venlafaxine (XR) Dominated Ref NICE All rights reserved. Page 26 of 63

27 Vortioxetine ,535 6,899 Duloxetine Dominated Dominated Agomelatine 1, ,955 57,955 Dominated fewer QALYs at greater cost than comparator. Abbreviations: ERG, Evidence Review Group; ICER, incremental cost-effectiveness ratio; n/a, not applicable; QALY, quality-adjusted life year; Ref, reference comparator; SSRI, selective serotonin re-uptake inhibitor; XR, extended release. Table 13 ERG exploratory analysis 3 assuming same relapse rate and average remission rate of second-line treatments (with up-titration) Costs QALYs Incremental Costs QALYs ICER with SSRI without SSRI (incremental analyses, in relation to next best) ERG scenario 1: Llorca et al. (2014) Escitalopram Ref Ref Ref n/a Venlafaxine (XR) ,778 Ref Vortioxetine ,434 36,434 Duloxetine Dominated Dominated Agomelatine Dominated Dominated ERG scenario 2: Pae et al. (2015) Venlafaxine (XR) Ref Ref Ref Ref Vortioxetine ,394 10,394 Duloxetine Dominated Dominated Agomelatine Dominated Dominated ERG scenario 3: Equal effectivenesseness NICE All rights reserved. Page 27 of 63

28 Escitalopram Ref Ref Ref n/a Venlafaxine (XR) Dominated Ref Vortioxetine ,752 7,882 Duloxetine Dominated Dominated Agomelatine , ,655 Dominated fewer QALYs at greater cost than comparator. Abbreviations: ERG, Evidence Review Group; ICER, incremental cost-effectiveness ratio; n/a, not applicable; QALY, quality-adjusted life year; Ref, reference comparator; SSRI, selective serotonin re-uptake inhibitor; XR, extended release. Table 14 ERG exploratory analysis 4 assuming same relapse rate and average remission rate with second-line use with proportionate reduction based on STAR*D (with up-titration) Incremental ICER Costs QALYs Costs QALYs with SSRI without SSRI (incremental analyses, in relation to next best) ERG scenario 1: Llorca et al. (2014) Escitalopram Ref Ref Ref n/a Venlafaxine (XR) Ref Vortioxetine Dominated Dominated Duloxetine Dominated Dominated Agomelatine Dominated Dominated ERG scenario 2: Pae et al. (2015) Venlafaxine (XR) Ref Ref Ref Ref Vortioxetine ,068 13,068 NICE All rights reserved. Page 28 of 63

29 Duloxetine ,583 14,583 Agomelatine Dominated Dominated ERG scenario 3: Equal effectivenesseness Escitalopram Ref Ref Ref n/a Venlafaxine (XR) Dominated Ref Vortioxetine ,270 7,992 Duloxetine Dominated Dominated Agomelatine , ,797 Dominated fewer QALYs at greater cost than comparator. Abbreviations: ERG, Evidence Review Group; ICER, incremental cost-effectiveness ratio; n/a, not applicable; QALY, quality-adjusted life year; Ref, reference comparator; SSRI, selective serotonin re-uptake inhibitor; XR, extended release. Company's additional evidence 3.43 The company provided additional evidence in its response to the appraisal consultation document. The company focused its additional evidence submission on people who had not tolerated, or whose major depressive episode had responded inadequately to, 2 antidepressants (hereafter referred to as the 'third-line population'). The company stated that there was no clinicaleffectiveness evidence available for vortioxetine in people having third-line treatment. The company did not carry out any additional searches for comparators, and so the available clinical-effectiveness evidence for vortioxetine and its comparators included: its original indirect treatment comparison for people having second-line treatment (see section 3.11), Pae et al. (2015), Llorca et al. (2014) and the SOLUTION trial provided with the response to the appraisal consultation document SOLUTION was an international, double-blind, randomised, active-control trial. It included 410 East Asian adults with recurrent moderate-to-severe major depressive disorder and did not exclude any people based on the line of treatment used for their current major depressive episode. Patients were randomised 1:1 to fixed doses of vortioxetine (10 mg daily) or venlafaxine NICE All rights reserved. Page 29 of 63

30 (150 mg daily). They were assessed weekly during the first 2 weeks of treatment and then every 2 weeks until the end of the 8-week treatment period. The primary outcome measure in SOLUTION was change from baseline in MADRS score at week 8. A 'full analysis set' population was used to test a primary hypothesis of non-inferiority. Non-inferiority was considered established if the upper bound of the two-sided 95% confidence interval of the difference between treatment groups in MADRS total score at week 8 did not exceed +2.5 MADRS units compared with venlafaxine. The mean change from baseline in MADRS total scores at week 8 were 19.4 points in the vortioxetine group and 18.2 points in the venlafaxine group. This resulted in a mean difference of 1.2 points in favour of vortioxetine (95% CI 3.0 to 0.6). At week 8, 43.1 and 41.4% of the people's major depressive episode had remitted in the vortioxetine group and venlafaxine group respectively. The company considered that the SOLUTION trial was relevant to the decision problem because it directly compared vortioxetine with venlafaxine The company noted that, as a third-line treatment, SSRIs were not offered in clinical practice in England and so were not relevant comparators for vortioxetine. The company revised its economic model structure so that it: defined treatment success, and decisions to switch treatment, by remission and response (rather than remission alone) used the time point when patients changed to another treatment because their condition did not respond to treatment from the trials for the time point in the model (8 weeks rather than 4 weeks) included a risk of relapse or recurrence at all stages of depression (rather than only in the acute or maintentance phase) used utility values from REVIVE (rather than using utility values from REVIVE for the acute phase and utility values from Sapin et al for the maintenance and recovery phases) included a 24-month time horizon (with discounting of costs and health effects after 12 months) The company adjusted the second-line remission rates used in its original economic model to reflect third-line remission rates used in its revised economic model using the proportional reduction observed in STAR*D between NICE All rights reserved. Page 30 of 63

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